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"I am not interested in being sent for tests or referred to another doctor, I just want some medicine to cure my cough." (chronic cougher)

"I used to refer to the DOTS centre, but I stopped. I would send my patients there, then never hear what happened. The patients would come back to me complaining the centre did nothing – just told them they did not have TB, but offered no help for their chronic cough." (service provider)

ICDDR,B’s Health and Family Planning Systems Programme (HFPSP) is broadly concerned with improving people’s access to healthcare in Bangladesh. It also seeks to boost the effectiveness of the country’s health services (both preventative and curative), and to improve service coverage. Using the best available evidence, the programme addresses key considerations such as health policy, service organization, funding and costs, and public–private sector interactions.

Early diagnosis of tuberculosis is often hampered by the fact that early in the infection adults may have only mild symptoms of a relatively non-specific nature. This includes a persistent cough – these ‘chronic coughers’ becoming a primary source of transmission. If the individual infected or his primary health care provider are aware that this is an important sign of early TB, it is hoped they will then refer themselves to a ‘direct observation and treatment (short course therapy)’ - DOTS centre. DOTS facilities have the required resources and trained health professionals to diagnose and properly treat and follow-up cases of tuberculosis. In Bangladesh it is estimated that 80% of TB cases seen at a DOTS centre are cured. On the other hand, less than 40% of adults with TB are ever seen in a DOTS facility. At present the primary strategy used to identify potential cases of TB is to refer any adult with a chough of three-or-more weeks duration to a DOTS centre.

The National Tuberculosis Programme (NTP) of Bangladesh is well aware of the shortcomings of early detection of recently infected adults and its chronic-cough referral strategy. In consultation with a team of HFPSP researchers important gaps in knowledge were identified that required urgent attention in the hopes of guiding future NTP programme strategies and health policy. The knowledge gaps included the following:

How common is a chronic cough among adults?
What are the health-seeking practices of those with a chronic cough?
If a ‘chronic cougher’ seeks help from a health care provider, what happens?
Are providers aware that they should suspect TB in an adult with a chronic cough, and do they refer such cases to a DOTS facility?

ICDDR,B researchers carried out surveys to identify chronic coughers in two lower-income, urban communities in Dhaka, and interviews of licensed and unlicensed providers in Dhaka and Chittagong, Bangladesh’s other large city corporation.

Door-to-door household surveys eventually reached over 60,000 adults, within which

1138 (1.9%) were identified to have a cough of more than 3 weeks’ duration. The prevalence of chronic cough was significantly higher in males (2.3%) than females (1.7%). Overall, this is not a very high prevalence of chronic cough, especially if one considers that over 90% of these individuals will not have TB. Even if every chronic cougher was referred to a DOTS centre, only about 2 early diagnoses per 2,000 people would be made, a rate much lower than the current estimates of TB prevalence in Dhaka.

We found that about two-thirds of those with a chronic cough had sought help from a health provider. Over 80% of these individuals sought help from private sector providers, of whom more than three-quarters were unlicensed. Unlicensed providers primarily practice allopathic medicine, copying the treatment practices of licensed providers, but in an unregulated environment. These include what are locally referred to as ‘village doctors’ or less frequently it might be a drug vendor or traditional healer. For early detection to be successful therefore, there is a need to work closely with the private sector, especially those who are unregulated. This does not mean they are unorganized; on the contrary, they have their local and national associations that are capable of representing them and influencing practices.

Adults found with a chronic cough were asked what measures had been taken by the private provider from whom care was sought. The interviews found that all providers frequently prescribe a drug. Unregulated providers infrequently order investigations. Most striking, we could find only one chronic cougher who was referred to a DOTS centre. In contrast to what symptomatic adults are reporting, the private providers we interviewed presented a very different picture. Less than one-half of providers were aware that they should suspect TB in an adult with a chronic cough. Unlicensed providers were the most out of line with what their patients were telling us: only 5% reported prescribing a drug and 75% claimed they referred chronic coughers to a DOTS centre.

These results tell us many important things. First, there are wide disparities between self-reported services received and what providers tell us they are practicing. Second, DOTS centres are not receiving referrals from the private sector in adequate enough frequency to have a substantial impact on TB detection in Dhaka or Chittagong. The situation may be different in rural Bangladesh and therefore the need to carry out similar surveys in these areas. Finally, the National TB Programme needs to consider new strategies and policies that will encourage greater public-private collaboration.

For more information on this study, contact Dr Shahed Hossain.